DNV Accreditation Process Flashcards
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Questions and Answers

What findings are verbal and why are they verbal only? (List 2 exceptions)

Noteworthy, Observation, and Opportunity for Improvement (OFI); exceptions: OFI listed on stroke and VAD DNV report.

A Corrective Action Plan (CAP) for all non-conformances must be submitted to DNV GL Healthcare USA, Inc. within __________ calendar days from the date of the Final report.

ten (10)

What are 3 things a CAP needs to contain?

Identify the cause of the nonconformity, actions taken to correct the nonconformity, other areas affected by the nonconformity.

The customer is expected to implement corrective action plans within ______________ from the date the CAP is approved.

<p>sixty (60) days</p> Signup and view all the answers

Failure to comply with the requirements of the CAP regarding nonconformities may also result in a _____________ _________________ ___________.

<p>Condition Level Finding</p> Signup and view all the answers

A _____________ _________________ ___________ could result in Jeopardy Status for the customer as described in Follow-up and Special Surveys.

<p>Condition Level Finding</p> Signup and view all the answers

CMS has determined that all Life Safety Code® (LSC) non-conformances must be corrected within ____ calendar days of the last day of survey.

<p>60</p> Signup and view all the answers

If the organization wishes to challenge a specific finding or nonconformance, what should the request be submitted as?

<p>Additional review</p> Signup and view all the answers

All Condition Level Findings not involving Immediate Jeopardy will require a follow-up survey within ______ calendar days of the last day of the survey.

<p>sixty (60)</p> Signup and view all the answers

When do Special Surveys occur? (Select all that apply)

<p>In response to a patient complaint</p> Signup and view all the answers

Failure to respond adequately to nonconformities identified during the accreditation process can lead to Immediate Jeopardy (of Accreditation Status).

<p>True</p> Signup and view all the answers

What notifications outline the requirements for removing an organization from Jeopardy Status?

<p>Jeopardy notification</p> Signup and view all the answers

Complaints will be prioritized as follows: (1) __________, (2) __________, (3) __________.

<p>Immediate Jeopardy, Operational (Response Required), Operational (No Response Required)</p> Signup and view all the answers

What is DNV?

<p>DNV stands for Det Norske Veritas, meaning 'the Norwegian truth' in Norwegian.</p> Signup and view all the answers

What does CMS stand for and what does CoP mean?

<p>Centers for Medicare and Medicaid Services (CMS) and Conditions of Participation (CoP).</p> Signup and view all the answers

What does NIAHO stand for?

<p>National Integrated Accreditation for Healthcare Organizations.</p> Signup and view all the answers

What are the two independent sets of standards that NIAHO uses?

<p>CMS standards and ISO 9001 Quality Management System.</p> Signup and view all the answers

Why is it important for hospitals to meet CMS standards?

<p>Patient safety and reimbursement for care.</p> Signup and view all the answers

What is ISO?

<p>ISO is the International Organization for Standardization.</p> Signup and view all the answers

What are the compliance requirements DNV requires?

<p>ISO 9001 standards and Medicare Conditions of Participation for Hospitals (42 CFR 482).</p> Signup and view all the answers

Why is it important for hospitals to meet ISO 9001 standards?

<p>It demonstrates a commitment to quality and helps with accreditation.</p> Signup and view all the answers

Healthcare systems that want to participate in the Medicare program must be in compliance with the ____________ by CMS.

<p>Medicare Conditions of Participation for Hospitals (42 C.F.R.§482).</p> Signup and view all the answers

Must we use DNV for our ISO certification according to NIAHO?

<p>False</p> Signup and view all the answers

DNV GL has been approved by CMS for deeming authority to determine healthcare organizations in compliance with Conditions of Participation since 2008.

<p>True</p> Signup and view all the answers

As of October 2021, how many private national accreditation organizations are approved by CMS?

<ol start="12"> <li></li> </ol> Signup and view all the answers

Continuing NIAHO accreditation will require a successful __________ survey.

<p>annual</p> Signup and view all the answers

When is a Full ISO compliance survey typically done?

<p>Triennially.</p> Signup and view all the answers

What is a typical schedule of Surveys for ISO and NIAHO?

<p>Year 1: NIAHO® Accreditation Survey; Year 2: NIAHO® Annual Survey and ISO 9001 Pre-Assessment; Year 3: NIAHO® Annual Survey and ISO 9001 Stage One Audit.</p> Signup and view all the answers

Failure to obtain ISO compliance in this timeframe will result in __________ __________ status.

<p>Accreditation Jeopardy</p> Signup and view all the answers

All DNV surveys are announced.

<p>False</p> Signup and view all the answers

DNV annual surveys have typically occurred in __________ of each year.

<p>January.</p> Signup and view all the answers

Currently accredited organizations are required to maintain current profile information on the DNV GL Healthcare customer website.

<p>True</p> Signup and view all the answers

For every DNV survey there is an _____________ and _____________ meeting.

<p>opening, closing</p> Signup and view all the answers

DNV surveyors can adjust assignments/locations based on information provided.

<p>True</p> Signup and view all the answers

Surveyors will first select patients that are __________ during the time of the survey.

<p>in the facility</p> Signup and view all the answers

The number of clinical records selected will typically be based on the organization's _____________.

<p>Average Daily Census (ADC)</p> Signup and view all the answers

Within the sample, surveyors will select at least _____ __________ from each nursing unit.

<p>one patient</p> Signup and view all the answers

What is the difference between an inpatient and an outpatient?

<p>An inpatient stays overnight in a hospital, while an outpatient does not.</p> Signup and view all the answers

It is common for a surveyor to educate hospital staff during a survey.

<p>True</p> Signup and view all the answers

Surveyors will conduct _____________ and ____________ interviews throughout the survey.

<p>formal, informal</p> Signup and view all the answers

Documents reviewed during the survey may include _____________ and _____________ Manuals.

<p>Policies, Procedure</p> Signup and view all the answers

What will the survey team do periodically during the survey?

<p>Meet to integrate findings.</p> Signup and view all the answers

What is the number of surveyors typically involved in DNV surveys at U of U Hospitals?

<p>Many. (12 in 2022, 11 in 2021)</p> Signup and view all the answers

How many business days does DNV provide a final written report after the survey?

<ol start="10"> <li></li> </ol> Signup and view all the answers

What will the final written survey report contain?

<p>All identified nonconformities related to NIAHO® requirements and/or ISO standards.</p> Signup and view all the answers

The organization has how many calendar days to request clarification on Nonconformity findings?

<ol start="10"> <li></li> </ol> Signup and view all the answers

What should organizations submit to DNV to address identified nonconformities?

<p>Corrective Action Plans.</p> Signup and view all the answers

What are the survey findings that indicate the severity of noncompliance?

<p>Immediate Jeopardy, Major Nonconformity, Minor Nonconformity, Observation, Opportunity for improvement, Noteworthy effort.</p> Signup and view all the answers

CMS requires that Life Safety Code non-conformances be corrected within how many calendar days?

<ol start="60"> <li></li> </ol> Signup and view all the answers

What is a Special Survey?

<p>A survey performed in response to complaints or significant media concerns.</p> Signup and view all the answers

For Category 1 Nonconformities, how many business days does an organization have to submit performance measures after the corrective action plan acceptance?

<ol start="60"> <li></li> </ol> Signup and view all the answers

For Category 2 Nonconformities, when will validation of the corrective action plan occur?

<p>At the next annual survey.</p> Signup and view all the answers

All Condition Level Findings will require an onsite follow-up survey no later than ____ ___________ ____________ following the survey.

<p>sixty calendar days</p> Signup and view all the answers

What may result from failure to comply with the requirements of the CAP regarding nonconformities?

<p>Condition Level Finding.</p> Signup and view all the answers

What is a noteworthy effort in terms of survey findings?

<p>A positive finding indicating an improvement or best practice.</p> Signup and view all the answers

What is an opportunity for improvement?

<p>A finding meeting minimum requirements but pointing out areas for potential enhancement.</p> Signup and view all the answers

What is an observation in survey findings?

<p>A finding without a clear reference to a standard requirement.</p> Signup and view all the answers

What does a Nonconformity (NC) - Category 2 finding indicate?

<p>A lapse of discipline or control without indicating a system breakdown.</p> Signup and view all the answers

What characterizes a Nonconformity (NC) Category 1 finding?

<p>Objective evidence of unmet requirements indicating significant potential for harm.</p> Signup and view all the answers

Study Notes

DNV Overview

  • DNV, originally Det Norske Veritas, translates to "the Norwegian truth" in Norwegian.
  • Established in 1864, focused on risk assessment for marine vessels.
  • Now a global leader in quality assurance and risk management, operating in over 100 countries.
  • Serves more than 100,000 clients in maritime, energy, food, healthcare, and other sectors.

CMS and CoP

  • The Centers for Medicare and Medicaid Services (CMS) establishes safety regulations for hospitals, called Conditions of Participation (CoP).

NIAHO Program

  • NIAHO stands for National Integrated Accreditation for Healthcare Organizations.
  • Offered by DNV GL Healthcare USA, it is the first integrated accreditation program in the U.S. for hospitals.
  • Combines multiple standards in the same survey process for efficiency.

Accreditation Standards

  • NIAHO uses:
    • CMS standards from the Centers for Medicare and Medicaid Services.
    • ISO 9001 standards from the International Organization for Standardization.

Importance of Compliance with Standards

  • Meeting CMS standards ensures patient safety and confirms effective service delivery.
  • Compliance is necessary for reimbursement from Medicare and Medicaid.

ISO Overview

  • ISO 9001, introduced in 1987, is a globally recognized quality management standard.
  • The latest version (ISO 9001:2015) was published on September 23, 2017, detailing quality management system requirements.

Compliance Requirements

  • DNV mandates compliance with both ISO 9001 standards and Medicare Conditions of Participation for hospitals (42 CFR 482).

Accreditation and Surveys

  • NIAHO accreditation requires successful annual surveys validating compliance with NIAHO and ISO standards.
  • ISO compliance surveys occur annually, while full ISO certification surveys take place triennially, often concurrently with NIAHO surveys.

Survey Schedule

  • Initial 3-year contract includes a NIAHO accreditation survey in the first year and annual follow-up surveys in subsequent years.
  • Failure to obtain ISO compliance within specified timeframes can lead to accreditation jeopardy.

Survey Process Details

  • All DNV surveys are unannounced, typically occurring in January, on Tuesdays or Wednesdays.
  • Accredited organizations must maintain updated profile information on the DNV GL Healthcare website.

Survey Findings and Documentation

  • Findings are categorized from most severe (Immediate Jeopardy) to least severe (Noteworthy Effort).
  • Organizations have 10 calendar days to challenge findings post-report and must submit corrective action plans within the same timeframe.

Categories of Nonconformities

  • Immediate Jeopardy, Major Nonconformities, Minor Nonconformities, Observations, Opportunities for Improvement, Noteworthy Efforts.
  • Life Safety Code non-conformances must be corrected within 60 calendar days of identification.

Special Surveys

  • Special Surveys can be initiated in response to complaints, unresolved media coverage issues, CMS concerns, or situations of Immediate Jeopardy.

Corrective Action Plans (CAP)

  • CAPs must address the cause of nonconformity, corrective actions taken, affected areas, process changes, timeframe for implementation, responsible persons, and performance measures for monitoring effectiveness.

Important Notes

  • Surveyors will conduct formal and informal interviews to gather information.
  • Nonconformities indicate lapses but may not signal a complete system breakdown.
  • Observations are findings without a clear standard reference or evidence, whereas opportunities for improvement identify areas for enhancement based on auditor experience.### Corrective Action Plans (CAP)
  • Customers must implement CAPs within sixty (60) days from approval.
  • DNV GL Healthcare evaluates extension requests on a case-by-case basis but rarely allows extensions beyond six (6) months.

Condition Level Findings

  • Noncompliance with CAP requirements may lead to a Condition Level Finding.
  • A Condition Level Finding can result in Jeopardy Status for the customer.

Life Safety Code® Non-Conformances

  • All LSC non-conformances must be corrected within sixty (60) calendar days post-survey.
  • Organizations can request a Time-Limited Waiver if unable to meet the correction timeframe.

Challenging Findings

  • Requests for additional reviews must be made in writing after receiving the final report.
  • Challenges are included in the Corrective Action Plan (CAP) submission with supporting evidence.

Follow-Up Surveys

  • Condition Level Findings not involving Immediate Jeopardy require a follow-up survey within sixty (60) calendar days.

Special Surveys

  • Occur in response to patient complaints, unresolved media issues, concerns flagged by CMS, or instances of Immediate Jeopardy.

Immediate Jeopardy Impact

  • Inadequate responses to nonconformities during accreditation can lead to Immediate Jeopardy status.

Jeopardy Status Requirements

  • The requirements and duration for removal from Jeopardy Status are detailed in the Jeopardy Notification.
  • Typically, an organization cannot remain in Jeopardy Status for more than four (4) months.

Complaint Handling

  • Complaints can come from CMS, federal or state agencies, patients or families, payers, caregivers, or other interested parties.
  • Complaints are prioritized as follows: Immediate Jeopardy, Operational (Response Required), Operational (No Response Required).

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Test your knowledge of the DNV accreditation process with these flashcards. Each card covers key concepts, historical context, and the evolution of DNV from its founding to its current role as a global leader in quality assurance and risk management.

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